Peptic ulcer of an anastomoz
Peptic ulcer of an anastomoz — postgastrorezektsionny ulcer defect in the field of a gastrointestinal soustya. It is shown by pain in an epigastriya, okolopupochny or right subcostal area, dyspepsia, weight loss, an asthenic syndrome. It is diagnosed by means of an ezofagogastroduodenoskopiya, a X-ray analysis of a stomach, ultrasonography of abdominal organs, a radio nuclide research, the histamine test, biochemical blood test. For treatment use antisekretorny, cytoprotective, antatsidny, antibacterial medicines, regeneration stimulators. In the absence of effect carry out a rerezektion, a vagotomiya, removal of a stomach or its part, parathyroid gland operation.
Peptic ulcer of an anastomoz
For the first time the German surgeon Mr. Brown reported about the peptic ulcer which arose at the patient from gastroenterostomy in 1899. Similar ulcer defect after a gastrorezektion was described by the Austrian surgeon Mr. Haberer in 1929. By results of observations, about 5-10% of gastroenterostomiya, 0,5-2% of resections of a stomach, 0,5-1% of antrumektomiya with crossing of the wandering nerve, 5-15% of the draining interventions with a vagotomiya are complicated by formation of an ulcer of an anastomoz. In 90-98% cases pathology is diagnosed for the patients operated concerning stomach ulcer of a duodenum. Feature of the recuring peptic ulcer is heavier current with bystry emergence of life-threatening complications.
Reasons of a peptic ulcer of an anastomoz
Defect of a mucous membrane in the field of a gastroyeyunalny soustya is usually formed because of technical errors and preservation of high level of secretion of the digesting components of gastric juice after performance of surgical intervention. On observations of experts in the field of gastroenterology, become the reasons of formation of an ulcer of an anastomoz:
- Unreasonably economical resection. During removal less than 2/3 stomachs the kislotoprodutsiruyushchy zone often remains. The situation is aggravated with refusal of crossing of the wandering nerve or its branches stimulating secretion of peptic factors.
- Technical errors of a resection on switching off. When performing operation on a method Billroth of II on a duodenal stump can partially remain antralny mucous. Because of switching off of sour current the specified site produces surplus of a gastrin.
- High tone of the wandering nerve. The parasympathetic nervous system stimulates release of peptic juice. At a vagusny hypertension or a combination of an economical gastrorezektion to an incomplete vagotomiya the prime cause of a peptic ulcer remains.
- Endocrine pathology. The recurrence of a disease is celebrated at 75% of patients with Zollingera-Ellison's syndrome. Repeated formation of an ulcer is also promoted by hyper secretion of gastric juice at a giperparatireoza (Vermer, Sippl, Shimke's syndromes).
Basis of development of a peptic ulcer of an anastomoz is the imbalance between the remained high level of production of the aggressive components of a gastric secret rendering the damaging effect on a mucous soustya and decrease of the activity of protective factors. Features of pathogenesis of a disease depend on the reasons which provoked a recurrence of stomach ulcer. At insufficient excision of a kislotoprodutsiruyushchy part of a stomach hydrochloric acid and pepsin are produced in the quantity almost comparable to the presurgical period.
In other cases the conditions promoting hyper stimulation of parietal and main cells of fundalny gastric glands — vagusny effect (come to light at a hyper tone or incomplete crossing of the wandering nerve), a gastrinemiya (at preservation of G-cages of a pilorichesky part, Zollingera-Ellison's syndrome), a giperkaltsiyemiya (at giperparatireoidny states). At the same time in a zone of an anastomoz as a result of postoperative violation of an innervation and blood supply production of slime, prostaglandins decreases, the epithelium is more slowly restored. As a result action of aggressive factors is insufficiently compensated by protective mechanisms, in a mucous soustya ulcer defect is gradually formed.
Symptoms of a peptic ulcer of an anastomoz
The disease develops from 6 months to 3 years after operation in time. Patients have intensive "hungry" and night pains which depending on a kind of the executed anastomoz have various localization (okolopupochny area, epigastriya, the right podreberye). Irradiation of pains in a left shoulder-blade, kardialny area, a waist is often observed. Intensity of pain becomes dull after food, reception of atropinsoderzhashchy medicines, sodium bicarbonate. There are dispepsichesky frustration: nausea, vomiting, heartburn, eructation sour, meteorizm, diarrhea. At the long course of a peptic ulcer of pain gain constant character, their emergence loses touch with meal or medicines. The violation of the general condition of the patient including deterioration in appetite, decrease in working capacity, loss of weight is observed. Subfebrilny body temperature is possible.
At some patients the ulcer penetration in the next bodies (a pancreas, a bryzheyka) with change of a typical rhythm and the nature of pains comes to light. When forming gastro fistula kalovy vomiting often is observed. A frequent complication of a peptic ulcer — the perforation which is followed by profuzny bleeding which demands immediate medical care. Sometimes there is an invagination of a lean gut in a stomach which is shown bloody vomiting, severe pains and emergence of opukholevidny education in epigastralny area. At a chronic course of disease the narrowing of an anastomoz leading to difficulties of passing of food can be formed. The ulcer malignization is in rare instances diagnosed.
Diagnosis of a peptic ulcer of an anastomoz does not represent difficulties in the presence of a characteristic clinical picture and data on the carried-out surgery. Diagnosis of a disease is directed to definition of localization and the extent of defect, identification of complications and the accompanying digestive tract pathologies. The most informative are:
- Ezofagogastroduodenoskopiya. Introduction of the flexible endoscope to a gullet and a stump of a stomach allows to estimate a condition of an anastomoz, to find ulcer defect, to reveal hyperaemia and puffiness of mucous. During endoscopy the biopsy of an affected area for the subsequent histologic research is carried out.
- Stomach X-ray analysis. Contrasting of a digestive tract by means of oral administration of sulfate of barium helps to find characteristic symptoms of a peptic ulcer on the roentgenogram — existence of "niche", convergence of folds mucous. The method is also applied to assessment of motor function of a stomach.
- Ultrasonography of an abdominal cavity. During ultrasonography it is possible to study structure of bodies of a digestive tract and gepatobiliarny system, a solvency of an anastomoz. The technique is supplemented with carrying out duplex scanning of vessels for detection of pathology of a chrevny trunk, belly department of an aorta.
- Radio nuclide research. Intravenous administration of medicine, marked a radioisotope, is carried out for definition of sekretorny function of a stump of a stomach. At a peptic ulcer excess accumulation of isotope in the field of an anastomoz is noted that testifies to the left site of antralny department.
- Histamine test. The method gives the chance to investigate basal and stimulated secretion of gastric glands. The research has high informational content for diagnostics of a syndrome of Zollingera-Ellison at which high activity of basal secretion, the weak response to hypodermic introduction of a histamine is noted.
In clinical blood test it is observed moderated , slight increase of SOE, can decrease amount of hemoglobin and erythrocytes that is a symptom of bleedings from a peptic ulcer. In biochemical blood test the gipoproteinemiya, increase in maintenance of a gastrin (is defined at Zollingera-Ellison's disease), increase in indicators of calcium and a paratgormon (at a giperparatireoza). The insulin test which positive result indicates safety of fibers of the wandering nerve is made for assessment of quality of the carried-out vagotomiya.
Differential diagnostics is carried out with other types of diseases of the operated stomach, malignant gastric neoplaziya, primary ulcer of a small intestine, insolvency of an anastomoz, an acute appendicitis, pancreatitis, cholecystitis. Except the gastroenterologist consultations of the surgeon, the oncologist, the hematologist, the endocrinologist are necessary for the patient.
Treatment of a peptic ulcer of an anastomoz
In most cases effective accords administration of drugs, reducing sekretorny function of a stomach — M-holinoretseptorov inhibitors, to H2-gistaminoblokatorov, inhibitors of a proton pomp in a combination with the cytoprotective, antatsidny, regenerating means. At a possible helikobakterioz antibacterial elimination of the activator by means of β-laktamny penicillin, macroleads, other antibiotics is carried out. Medicamentous therapy is supplemented with correction of a diet. Expeditious treatment is recommended to patients with therapeutic resistant peptic ulcer, gastrinomy, the complicated course of a disease. Taking into account a clinical situation carry out:
- Corrective operations. Allow to eliminate mechanical or functional violations of digestion. Creation of conditions for the most physiological digestion of food is provided by a rerezektion with creation of a new anastomoz, transthoracic or poddiafragmalny stem, selective proximal vagotomiya, combination of these operations.
- Removal of the struck part or body. At a repeated peptic ulcer removal of a benign tumor of a stomach (a solitary gastrinoma), a stomach resection with a vagotomiya, a total gastrektomiya is shown to patients with Zollingera-Ellison's disease. Subtotal or total removal of parathyroid glands is made for correction of a gipertireoz.
Forecast and prevention
Postoperative gastroyeyunalny ulcers are characterized by a recidivous current with frequent complications. The forecast is rather adverse, at the weakened patients with the heavy accompanying pathologies the risk of a lethal outcome increases. Prevention of peptic ulcers consists in the careful choice of a method of creation of an anastomoz, carrying out a resection not less than two thirds of a stomach for decrease in kislotoprodutsiruyushchy function, observance of the technology of surgical intervention, purpose of effective conservative therapy for an eradikation of a helikobakterny infection before operation, treatment of associated diseases.